Transcript Chapter 12: Fluency Disorders

Chapter 12:
Fluency Disorders
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.1
Focus Questions
• What is a fluency disorder?
• How are fluency disorders classified?
• What are the defining characteristics of
fluency disorders?
• How are fluency disorders identified?
• How are fluency disorders treated?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.2
Introduction – Fluency Disorders
• Ability to produce speech effortlessly and
automatically is compromised
• Better known as stuttering
• Relatively small number of persons
affected compared to other communication
disorders – 1 to 2% of population at a
given time
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.3
The Familiarity of Stuttering
• Despite the low incidence, the general
population seems to be most familiar with
fluency disorders – WHY?
– Perhaps longest documented history of any
communication disorder
– Affected some famous faces, including
contemporary celebrities
– Often used in the media, either comically or
as a dramatic, metaphoric technique
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.4
What you may not know…
• Most young children go through a period
of disfluency (up to 5% of their speech)
• Majority of cases in children are resolved,
either spontaneously or through treatment
• Many of the public perceptions of people
with fluency disorders are not accurate,
such as being timid or fearful
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.5
Case Study #1: Ralston
• 4-year old boy in private day care center in West
Virginia
– family (consisting of mother, father, and four siblings)
lives in two-bedroom subsidized apartment
• Social and communicative child, but recently day
care teacher has noticed stuttering and more
frequent temper tantrums
• Mother says not to worry, that older siblings also
went through this stage, but teacher is worried
that the stuttering might interfere with Ralston’s
interactions with the other children and that it
might be related to the tantrums
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.6
Case Study #1 Questions
• What warning signs should Ms. Henry look
for when documenting Ralston’s stuttering
behaviors?
• What are some strategies Ms. Henry might
use in the day care center to promote
Ralston’s ability to effectively
communicate?
• What are some events or challenges in
Ralston’s life that might be related to the
emergence of disfluencies?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.7
Case Study #2: Kaimon
• 7-year old boy just starting second grade
– treated for fluency disorder in K – 1st grades, but
dismissed from treatment
• Mr. Damon, teacher, reports that Kaimon is
still stuttering and using avoidance tactics
• Kaimon doesn’t want to go to therapy again,
and his teacher agreed to try different
strategies in the classroom for next three
months
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.8
Case Study #2 Questions
• What are some strategies that Mr. Damon
might use to promote peer acceptance of
children with communication disabilities in
his classroom?
• What are some strategies that Mr. Damon
might use in the next few months to
increase Kaimon’s fluency and decrease
his disfluency within the classroom?
• Do you agree or disagree with Kaimon’s
parents for keeping him out of therapy for
the next few months? Why or why not?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.9
Case Study #3: Mr. Cho
• 39-year old suffered a stroke during heart surgery
– paralyzed on right side and exhibits communication
impairments, including severe fluency problem
• Shows pauses, interjections, repetitions, and
prolongations, but no fear or embarrassment
• Insurance only covers 12 sessions of outpatient
therapy, but he’s using those for physical therapy
• Decided to pay out-of-pocket $1,200 for a 3-month
vitamin treatment that claims 100% cure for
acquired stuttering that his daughter found
advertised in the newspaper
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.10
Case Study #3 Questions
• Do you agree with Mr. Cho’s decision to
forfeit the outpatient speech therapy in lieu
of the physical therapy and to pursue the
vitamin treatment?
• How can a consumer differentiate between
those treatments that are effective and
those that are questionable?
• What other explanations are possible to
explain Mr. Cho’s improved fluency
following two months of a special vitamin
regimen?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.11
I. What is a Fluency Disorder?
• What is fluency?
– Speech moves at an appropriate rate
– Easy rhythm
– Smoothness
– Effortless
– Automatic
• Disfluency occurs when there is a
disruption in any of these elements
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.12
Fluency Disorders
• Unusually high rate of stoppages that disrupt the
flow of communication and re inappropriate for a
person’s age, culture, and linguistic background
• Three essential characteristics:
– Disturbance in the normal fluency and timing patterns
of speech
– Disturbance in social communication, academic
performance, or occupational achievement
– If another disability is present, the fluency disturbance
is in excess of what is expected of that disability
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.13
Core and Secondary Features
• Core features: primary characteristics of a
fluency disorder
– Repetitions
– Prolongations
– Blocks
• Secondary features: emerge in response to the
core behaviors
– Avoid and escape moments of disfluency, such as
eye blinks, head jerks, pauses, fillers
– Negative feelings and attitudes, such as worrying
about speaking, viewing speaking as difficult
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.14
Terminology
• Stuttering: describes fluency disorder
• Stutterer: describes a person affected by a
fluency disorder
• Person first language gives the individual
primacy over the disorder (e.g., “child who
stutters”)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.15
Prevalence and Incidence
• Incidence: 1 in 100 persons
• Prevalence: 5 in 100 persons
• Affect children between the ages of two
and 10 years at the highest rates
• Males are affected at a higher rate than
females (approximately 3:1)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.16
Recovery from Stuttering
• Difference between prevalence and incidence
rates indicate that the majority of persons (perhaps
80%) who exhibit fluency disorders do recover
• Raises question concerning need for treatment
(i.e., to treat or to wait and see)
• Three reasons why treatment is necessary:
– Children who recover from stuttering often do experience
stuttering for a relatively long time
– No way to know whether children will eventually recover
or not
– Relatively high rate of co-occurring speech and
language problems that exist beyond fluency disorder
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.17
II. How are Fluency Disorders
Classified?
A. Etiology-Focused Classification
• Developmental Disorder of Fluency:
– Emerges in early childhood (2-5 years) and its cause
is unknown
– Characterized by stuttering-like dysfluencies (SLDs):
part- and single-syllable word repetitions,
prolongations, and blocks
• Acquired Disorder of Fluency:
– Dramatic onset anytime in lifespan, resulting from
illness, trauma, accident, or psychological trauma
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.18
B. Symptom-Focused Classification
• Several systems exist to describe fluency
disorders in terms of how far they have
advanced
• Peters and Guitar’s 5-Level System:
– Normal disfluency: 18 mos. – 6 yrs. of age
– Borderline stuttering: (18 mos. – 6 yrs.)
produce more and different types of
disfluencies than normal
– Beginning stuttering: (2 – 8 yrs.) true fluency
disorder
– Intermediate stuttering: 6 – 13 years
– Advanced stuttering: over 14 years
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.19
Cluttering
• Cluttering:
– Breakdowns at the word or phrase level
– Poor cohesion and coherence in expressing
thoughts and organizing sentences
– Fast and spurty speaking rate
– Reduced intelligibility
– NOT inhibited or anxious about speaking
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.20
III. Defining Characteristics of
Fluency Disorders
• Core Features
– Within-word and between-word disfluencies
• Secondary Features
– Escape behaviors
– Avoidance behaviors
– Feelings and Attitudes
• Causes and Risk Factors
– Predisposing factors
– Precipitating factors
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.21
Core Features
1. Part-word repetition: sound or syllable is
repeated 2 to 4 times
2. Single-syllable word repetition: two or more
times
3. Sound prolongation: duration of speech
sound is lengthened
4. Block: articulators and airflow completely
stop during the production of a sound
• Within-word disfluencies (stuttering) vs.
between-word disfluencies (normal)
Justice
Communication
Sciences and Disorders: An Introduction
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle
New Jersey
07458Inc.
Copyright
©2006River,
by Pearson
Education,
All rights
reserved.
Upper Saddle River,
New Jersey
07458
All rights reserved.
12.22
Secondary Features
• Escape behaviors: response to moments of
stuttering
– Head nods, eye blinking, leg slapping
• Avoidance behaviors: avoid moments of
stuttering
– Word and sound avoidance (substitution,
circumlocution, postponement)
– Situation avoidance
• Feelings and attitudes: negative feelings
towards communication
– Fear, embarrassment, shame
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.23
Causes and Risk Factors
• For the majority of children, stuttering
begins for no apparent reason
• Hard to identify, because results from
complex interaction of two types of factors:
– Predisposing: individual’s constitutional
factors that make him susceptible to a fluency
disorder (70% of likelihood)
– Precipitating: developmental and
environmental factors that can worsen
stuttering (30%)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.24
Predisposing Factors
• Family history: tendency to run in families,
and genetic link seen in twin studies
• Gender: boys are more likely to develop a
fluency disorder and slower to recover
• Processing ability: underlying problem with
linguistic processing (demand and
capacity model)
• Motor-speech coordination: difficulty in
coordinating and timing the motor activities
required for fluent speech
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.25
Precipitating Factors
• Age: average age of emergence is 3 years for boys
and 2.5 years for girls
• Development stressors:
– Stressful adult speech models: children exposed to adult
speech not appropriate for their own speech, language,
and cognitive abilities
– Stressful speaking situations for children: competing or
hurrying to speak, having too many things to say
– Stressful life events: moving, divorce of parents, loss of
family member, illness, or accident
• Self awareness: atypically high awareness of own
disfluencies
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.26
IV. How are Fluency Disorders
Identified?
• Determine if the quality and/or quantity of
disfluencies significantly differ from normal
• Quantity: two common metrics
– Average # of disfluencies per 100 words
– Average # of disfluencies per 100 syllables
• Quality:
– Normal: interjection and revisions
predominate
– Disordered: repetitions, prolongations, and
blocks predominate
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.27
The Assessment Process
•
•
•
•
•
•
Referral
Assessment Protocol
Diagnosis
Severity
Prognosis
Treatment Recommendations
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.28
Referral
• Important for other professionals to recognize
warning signs and make referrals to SLPs
• Warning signs for developmental fluency
disorders:
– Repetition of words or parts of words that involve 3 or
more repetitions, prolongation of a sound, feelings of
frustration or embarrassment towards communication
• Warning signs for acquired fluency disorders:
– “stuttering-like” or “cluttering-like” disfluencies,
inability to effectively communicate
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.29
Assessment Protocol
•
Four main questions:
1. Is the child stuttering or at-risk for stuttering?
2. Does the child exhibit other communicative
risk factors or disabilities?
3. Is therapy for stuttering warranted?
4. What therapy approach is most beneficial?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.30
Assessment Protocol
• Variety of tools:
– Case history and interview
– Speech observation
– Questionnaire and survey
– Direct testing
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.31
Diagnosis
• More likely to be diagnosed if the following
are observed during assessment:
– At least 10 total disfluencies per 100 words
– At least 3 total “stuttering-like” disfluencies per
100 words
– Physical escape behaviors
– Verbal avoidance behaviors
• Also need to determine the severity,
prognosis, and treatment
recommendations
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.32
• Severity:
– Stuttering Severity Index (SSI): based on
frequency of disfluencies, duration of blocks,
and physical concomitants
• very mild, mild, moderate, severe, very severe
• Prognosis:
– Subjective decision of likelihood that the
symptoms will resolve with time and/or
treatment based on several factors (e.g., age
of onset, presence of other risk factors)
• Treatment Recommendations:
– Specific course of action based on evidencebased practice
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.33
V. How are Fluency Disorders
Treated?
A. Borderline Stuttering:
• Early intervention vs. “wait and see”
approach
• Indirect treatments:
– Environmental modification models
– Operant training models
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.34
B. Beginning Stuttering
•
•
Treatment goal: eliminate core disfluencies
(secondary are not apparent yet)
Current Approaches:
– Stuttering modification therapy
– Fluency shaping therapy
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
12.35
C. Intermediate and Advanced Stuttering
• Secondary features now characterize
these levels
• Treatment for adolescents:
– Already a challenging period of life
– Stuttering modification: teaching about
stuttering and how to work through it
– Fluency shaping: smooth speech treatment
• Treatment for adults:
– Emphasizes knowledge about stuttering,
reduction of negative feelings, and fluency
building
– Pharmaceutical intervention is being explored
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.